Provider Demographics
NPI:1053335133
Name:MOORE, WESLEY S (MD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:S
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 UCLA MEDICAL PLZ STE 526
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-6908
Practice Address - Country:US
Practice Address - Phone:310-267-0172
Practice Address - Fax:310-725-4037
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA192662086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A19266OtherBLUE SHIELD
CAA19266OtherBLUE CROSS
CAP00168682OtherMEDICARE PIN
CAA21681Medicare UPIN
CAA19266Medicare PIN